"Variable / Field Name","Form Name","Field Units","Section Header","Field Type","Field Label","Choices OR Calculations","Field Note","Text Validation Type","Text Validation Min","Text Validation Max",Identifier?,"Branching Logic (Show field only if...)","Required Field?"
study_id,demographics,,,text,"Study ID",,,,,,,,
date_enrolled,demographics,,"Demographic Characteristics",text,"Date subject signed consent",,YYYY-MM-DD,date,,,,,
first_name,demographics,,,text,"First Name",,,,,,y,,
last_name,demographics,,,text,"Last Name",,,,,,y,,
address,demographics,,"Contact Information",notes,"Street, City, State, ZIP",,,,,,y,,
telephone_1,demographics,,,text,"Phone number",,"Include Area Code",phone,,,y,,
telephone_2,demographics,,,text,"Second phone number",,"Include Area Code",phone,,,y,,
email,demographics,,,text,E-mail,,,email,,,y,,
sex,demographics,,,dropdown,Gender,"0, Female | 1, Male",,,,,,,y
given_birth,demographics,,,dropdown,"Has the subject given birth before?","0, No | 1, Yes",,,,,,"[sex] = ""0""",
num_children,demographics,,,text,"How many times has the subject given birth?",,,integer,0,,,"[sex] = ""0"" and [given_birth] = ""1""",
ethnicity,demographics,,,radio,Ethnicity,"0, Hispanic or Latino | 1, NOT Hispanic or Latino | 2, Unknown / Not Reported",,,,,,,
race,demographics,,,radio,Race,"0, American Indian/Alaska Native | 1, Asian | 2, Native Hawaiian or Other Pacific Islander | 3, Black or African American | 4, White | 5, More Than One Race | 6, Unknown / Not Reported",,,,,,,
dob,demographics,,,text,"Date of birth",,,date,,,y,,
age,demographics,,,calc,"Age (years)","round(datediff([dob],'today','y'),1)",,,,,,,
height,demographics,cm,,text,"Height (cm)",,,number,130,215,,,
weight,demographics,kilograms,,text,"Weight (kilograms)",,,integer,35,200,,,
bmi,demographics,kilograms,,calc,BMI,"round(([weight]*10000)/(([height])^(2)),1)",,,,,,,
patient_document,demographics,,,file,"Patient document",,,,,,,,
meds,demographics,,,checkbox,"Is patient taking any of the following medications? (check all that apply)","1, Lexapro | 2, Celexa | 3, Prozac | 4, Paxil | 5, Zoloft",,,,,,,
diabetes,demographics,,,dropdown,"Patient has a diagnosis of diabetes mellitus?","0, No | 1, Yes",,,,,,,
diabetes_type,demographics,,,dropdown,"Type of Diabetes Mellitus","0, Type 1 insulin-dependent | 1, Type 2 insulin-dependent | 2, Type 2 non insulin-dependent",,,,,,,
dialysis_initiation,demographics,,"Dialysis Information",text,"Date of first outpatient dialysis treatment",,,date,,,,,
access_type,demographics,,,dropdown,"Type of vascular access","0, Graft | 1, Fistula | 2, Catheter with maturing graft | 3, Catheter with maturing fistula",,,,,,,
access_location,demographics,,,dropdown,"Location of currently used vascular access","0, Forearm | 1, Upper arm | 2, Internal jugular vein | 3, Subclavian vein | 4, Other",,,,,,,
dialysis_unit_name,demographics,,,text,"Name of dialysis unit",,,,,,,,
dialysis_unit_phone,demographics,,,text,"Phone number",,"Include Area Code",phone,,,,,
dialysis_schedule_days,demographics,,,radio,"Days of the week patient is dialyzed","0, Monday-Wednesday-Friday | 1, Tuesday-Thursday-Saturday | 2, Other",,,,,,,
dialysis_schedule_time,demographics,,,dropdown,"Shift patient is dialyzed","0, First shift | 1, Second shift | 2, Third shift | 3, Fourth shift",,,,,,,
etiology_esrd,demographics,,,dropdown,"Etiology of ESRD","0, Diabetes | 1, Hypertension | 2, Glomerulonephritis | 3, Polycystic Kidney Disease | 4, Interstitial Nephritis | 5, Hereditary Nephritis | 6, Other",,,,,,,
subject_comments,demographics,,"General Comments",notes,Comments,,,,,,,,
date_visit_b,baseline_data,,"Baseline Measurements",text,"Date of baseline visit",,,date,,,,,
date_blood_b,baseline_data,,,text,"Date blood was drawn",,,date,,,,,
alb_b,baseline_data,g/dL,,text,"Serum Albumin (g/dL)",,,integer,3,5,,,
prealb_b,baseline_data,mg/dL,,text,"Serum Prealbumin (mg/dL)",,,number,10,40,,,
creat_b,baseline_data,mg/dL,,text,"Creatinine (mg/dL)",,,number,0.5,20,,,
npcr_b,baseline_data,g/kg/d,,text,"Normalized Protein Catabolic Rate (g/kg/d)",,,number,0.5,2,,,
chol_b,baseline_data,mg/dL,,text,"Cholesterol (mg/dL)",,,number,100,300,,,
transferrin_b,baseline_data,mg/dL,,text,"Transferrin (mg/dL)",,,number,100,300,,,
kt_v_b,baseline_data,,,text,Kt/V,,,number,0.9,3,,,
drywt_b,baseline_data,kilograms,,text,"Dry weight (kilograms)",,,number,35,200,,,
plasma1_b,baseline_data,,,dropdown,"Collected Plasma 1?","0, No | 1, Yes",,,,,,,
plasma2_b,baseline_data,,,dropdown,"Collected Plasma 2?","0, No | 1, Yes",,,,,,,
plasma3_b,baseline_data,,,dropdown,"Collected Plasma 3?","0, No | 1, Yes",,,,,,,
serum1_b,baseline_data,,,dropdown,"Collected Serum 1?","0, No | 1, Yes",,,,,,,
serum2_b,baseline_data,,,dropdown,"Collected Serum 2?","0, No | 1, Yes",,,,,,,
serum3_b,baseline_data,,,dropdown,"Collected Serum 3?","0, No | 1, Yes",,,,,,,
sga_b,baseline_data,,,text,"Subject Global Assessment (score = 1-7)",,,number,0.9,7.1,,,
date_supplement_dispensed,baseline_data,,,text,"Date patient begins supplement",,,date,,,,,
date_visit_1,month_1_data,,"Month 1",text,"Date of Month 1 visit",,,date,,,,,
alb_1,month_1_data,g/dL,,text,"Serum Albumin (g/dL)",,,number,3,5,,,
prealb_1,month_1_data,mg/dL,,text,"Serum Prealbumin (mg/dL)",,,number,10,40,,,
creat_1,month_1_data,mg/dL,,text,"Creatinine (mg/dL)",,,number,0.5,20,,,
npcr_1,month_1_data,g/kg/d,,text,"Normalized Protein Catabolic Rate (g/kg/d)",,,number,0.5,2,,,
chol_1,month_1_data,mg/dL,,text,"Cholesterol (mg/dL)",,,number,100,300,,,
transferrin_1,month_1_data,mg/dL,,text,"Transferrin (mg/dL)",,,number,100,300,,,
kt_v_1,month_1_data,,,text,Kt/V,,,number,0.9,3,,,
drywt_1,month_1_data,kilograms,,text,"Dry weight (kilograms)",,,number,35,200,,,
no_show_1,month_1_data,,,text,"Number of treatments missed",,,number,0,7,,,
compliance_1,month_1_data,,,dropdown,"How compliant was the patient in drinking the supplement?","0, 100 percent | 1, 99-75 percent | 2, 74-50 percent | 3, 49-25 percent | 4, 0-24 percent",,,,,,,
hospit_1,month_1_data,,"Hospitalization Data",dropdown,"Was patient hospitalized since last visit?","0, No | 1, Yes",,,,,,,
cause_hosp_1,month_1_data,,,dropdown,"What was the cause of hospitalization?","1, Vascular access related events | 2, CVD events | 3, Other",,,,,,,
admission_date_1,month_1_data,,,text,"Date of hospital admission",,,date,,,,,
discharge_date_1,month_1_data,,,text,"Date of hospital discharge",,,date,,,,,
discharge_summary_1,month_1_data,,,dropdown,"Discharge summary in patients binder?","0, No | 1, Yes",,,,,,,
death_1,month_1_data,,"Mortality Data",dropdown,"Has patient died since last visit?","0, No | 1, Yes",,,,,,,
date_death_1,month_1_data,,,text,"Date of death",,,date,,,,,
cause_death_1,month_1_data,,,dropdown,"What was the cause of death?","1, All-cause | 2, Cardiovascular",,,,,,,
date_visit_2,month_2_data,,"Month 2",text,"Date of Month 2 visit",,,date,,,,,
alb_2,month_2_data,g/dL,,text,"Serum Albumin (g/dL)",,,number,3,5,,,
prealb_2,month_2_data,mg/dL,,text,"Serum Prealbumin (mg/dL)",,,number,10,40,,,
creat_2,month_2_data,mg/dL,,text,"Creatinine (mg/dL)",,,number,0.5,20,,,
npcr_2,month_2_data,g/kg/d,,text,"Normalized Protein Catabolic Rate (g/kg/d)",,,number,0.5,2,,,
chol_2,month_2_data,mg/dL,,text,"Cholesterol (mg/dL)",,,number,100,300,,,
transferrin_2,month_2_data,mg/dL,,text,"Transferrin (mg/dL)",,,number,100,300,,,
kt_v_2,month_2_data,,,text,Kt/V,,,number,0.9,3,,,
drywt_2,month_2_data,kilograms,,text,"Dry weight (kilograms)",,,number,35,200,,,
no_show_2,month_2_data,,,text,"Number of treatments missed",,,number,0,7,,,
compliance_2,month_2_data,,,dropdown,"How compliant was the patient in drinking the supplement?","0, 100 percent | 1, 99-75 percent | 2, 74-50 percent | 3, 49-25 percent | 4, 0-24 percent",,,,,,,
hospit_2,month_2_data,,"Hospitalization Data",dropdown,"Was patient hospitalized since last visit?","0, No | 1, Yes",,,,,,,
cause_hosp_2,month_2_data,,,dropdown,"What was the cause of hospitalization?","1, Vascular access related events | 2, CVD events | 3, Other",,,,,,,
admission_date_2,month_2_data,,,text,"Date of hospital admission",,,date,,,,,
discharge_date_2,month_2_data,,,text,"Date of hospital discharge",,,date,,,,,
discharge_summary_2,month_2_data,,,dropdown,"Discharge summary in patients binder?","0, No | 1, Yes",,,,,,,
death_2,month_2_data,,"Mortality Data",dropdown,"Has patient died since last visit?","0, No | 1, Yes",,,,,,,
date_death_2,month_2_data,,,text,"Date of death",,,date,,,,,
cause_death_2,month_2_data,,,dropdown,"What was the cause of death?","1, All-cause | 2, Cardiovascular",,,,,,,
date_visit_3,month_3_data,,"Month 3",text,"Date of Month 3 visit",,,date,,,,,
date_blood_3,month_3_data,,,text,"Date blood was drawn",,,date,,,,,
alb_3,month_3_data,g/dL,,text,"Serum Albumin (g/dL)",,,number,3,5,,,
prealb_3,month_3_data,mg/dL,,text,"Serum Prealbumin (mg/dL)",,,number,10,40,,,
creat_3,month_3_data,mg/dL,,text,"Creatinine (mg/dL)",,,number,0.5,20,,,
npcr_3,month_3_data,g/kg/d,,text,"Normalized Protein Catabolic Rate (g/kg/d)",,,number,0.5,2,,,
chol_3,month_3_data,mg/dL,,text,"Cholesterol (mg/dL)",,,number,100,300,,,
transferrin_3,month_3_data,mg/dL,,text,"Transferrin (mg/dL)",,,number,100,300,,,
kt_v_3,month_3_data,,,text,Kt/V,,,number,0.9,3,,,
drywt_3,month_3_data,kilograms,,text,"Dry weight (kilograms)",,,number,35,200,,,
plasma1_3,month_3_data,,,dropdown,"Collected Plasma 1?","0, No | 1, Yes",,,,,,,
plasma2_3,month_3_data,,,dropdown,"Collected Plasma 2?","0, No | 1, Yes",,,,,,,
plasma3_3,month_3_data,,,dropdown,"Collected Plasma 3?","0, No | 1, Yes",,,,,,,
serum1_3,month_3_data,,,dropdown,"Collected Serum 1?","0, No | 1, Yes",,,,,,,
serum2_3,month_3_data,,,dropdown,"Collected Serum 2?","0, No | 1, Yes",,,,,,,
serum3_3,month_3_data,,,dropdown,"Collected Serum 3?","0, No | 1, Yes",,,,,,,
sga_3,month_3_data,,,text,"Subject Global Assessment (score = 1-7)",,,number,0.9,7.1,,,
no_show_3,month_3_data,,,text,"Number of treatments missed",,,number,0,7,,,
compliance_3,month_3_data,,,dropdown,"How compliant was the patient in drinking the supplement?","0, 100 percent | 1, 99-75 percent | 2, 74-50 percent | 3, 49-25 percent | 4, 0-24 percent",,,,,,,
hospit_3,month_3_data,,"Hospitalization Data",dropdown,"Was patient hospitalized since last visit?","0, No | 1, Yes",,,,,,,
cause_hosp_3,month_3_data,,,dropdown,"What was the cause of hospitalization?","1, Vascular access related events | 2, CVD events | 3, Other",,,,,,,
admission_date_3,month_3_data,,,text,"Date of hospital admission",,,date,,,,,
discharge_date_3,month_3_data,,,text,"Date of hospital discharge",,,date,,,,,
discharge_summary_3,month_3_data,,,dropdown,"Discharge summary in patients binder?","0, No | 1, Yes",,,,,,,
death_3,month_3_data,,"Mortality Data",dropdown,"Has patient died since last visit?","0, No | 1, Yes",,,,,,,
date_death_3,month_3_data,,,text,"Date of death",,,date,,,,,
cause_death_3,month_3_data,,,dropdown,"What was the cause of death?","1, All-cause | 2, Cardiovascular",,,,,,,
complete_study,completion_data,,"Study Completion Information",dropdown,"Has patient completed study?","0, No | 1, Yes",,,,,,,
withdraw_date,completion_data,,,text,"Put a date if patient withdrew study",,,date,,,,,
withdraw_reason,completion_data,,,dropdown,"Reason patient withdrew from study","0, Non-compliance | 1, Did not wish to continue in study | 2, Could not tolerate the supplement | 3, Hospitalization | 4, Other",,,,,,,
complete_study_date,completion_data,,,text,"Date of study completion",,,date,,,,,
study_comments,completion_data,,"General Comments",notes,Comments,,,,,,,,
fatexp20_0d31d8,promis_fatigue__short_form_7a,,"Please respond to each item by marking one answer per question.<br><br>In the past 7 days...",radio,"How often did you feel tired?...","1, 1 Never | 2, 2 Rarely | 3, 3 Sometimes | 4, 4 Often | 5, 5 Always",,,,,,,
fatexp5_d80a4c,promis_fatigue__short_form_7a,,,radio,"How often did you experience extreme exhaustion?...","1, 1 Never | 2, 2 Rarely | 3, 3 Sometimes | 4, 4 Often | 5, 5 Always",,,,,,,
fatexp18_396fe5,promis_fatigue__short_form_7a,,,radio,"How often did you run out of energy?...","1, 1 Never | 2, 2 Rarely | 3, 3 Sometimes | 4, 4 Often | 5, 5 Always",,,,,,,
fatimp33_a9e236,promis_fatigue__short_form_7a,,,radio,"How often did your fatigue limit you at work (include work at home)?...","1, 1 Never | 2, 2 Rarely | 3, 3 Sometimes | 4, 4 Often | 5, 5 Always",,,,,,,
fatimp30_5f4d82,promis_fatigue__short_form_7a,,,radio,"How often were you too tired to think clearly?...","1, 1 Never | 2, 2 Rarely | 3, 3 Sometimes | 4, 4 Often | 5, 5 Always",,,,,,,
fatimp21_de19f3,promis_fatigue__short_form_7a,,,radio,"How often were you too tired to take a bath or shower?...","1, 1 Never | 2, 2 Rarely | 3, 3 Sometimes | 4, 4 Often | 5, 5 Always",,,,,,,
fatimp40_f7e5db,promis_fatigue__short_form_7a,,,radio,"How often did you have enough energy to exercise strenuously?...","5, 5 Never | 4, 4 Rarely | 3, 3 Sometimes | 2, 2 Often | 1, 1 Always",,,,,,,
